DOCSLIB.ORG

Physical Examination of the Knee: a Review of the Original Test Description and Scientific Validity of Common Orthopedic Tests Gerard A

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Physical Examination of the Knee: a Review of the Original Test Description and Scientific Validity of Common Orthopedic Tests Gerard A 592 REVIEW ARTICLE Physical Examination of the Knee: A Review of the Original Test Description and Scientific Validity of Common Orthopedic Tests Gerard A. Malanga, MD, Steven Andrus, MD, Scott F. Nadler, DO, James McLean, MD ABSTRACT. Malanga GA, Andrus S, Nadler SF, McLean J. tion on the sensitivity and specificity along with other infor- Physical examination of the knee: a review of the original test mation about the validity of these tests in clinical practice. To description and scientific validity of common orthopedic tests. standardize how physical examinations are performed and Arch Phys Med Rehabil 2003;84:592-603. compared, they should follow the original description or agreed-on standards. In addition, the significance of a physical Objectives: To present the original descriptions of common examination finding must be understood to ensure that patients orthopedic physical examination maneuvers of the knee and with knee complaints are accurately diagnosed and properly then to review the literature to support the scientific validity of treated. these tests. Key Words: Anterior cruciate ligament; Knee; Menisci, Data Sources: MEDLINE (1970–2000) searches were per- tibial; Physical examination; Posterior cruciate ligament; Re- formed, as were reviews of various musculoskeletal examina- habilitation. tion textbooks that describe physical examination maneuvers of © 2003 by the American Congress of Rehabilitation Medi- the knee. These references were then reviewed for additional cine and the American Academy of Physical Medicine and references and crossed back to the original description (when Rehabilitation possible) of these named tests. Study Selection: All articles that discussed the sensitivity USCULOSKELETAL PROBLEMS are among the most and specificity of the physical examination maneuvers were 1 extracted. This information was reviewed for accuracy and Mcommon reasons for patient visits to physicians. Unfor- tunately, it seems that most physicians are not adequately then summarized. 2-5 Data Extraction: Multiple MEDLINE and text searches trained in the evaluation of many musculoskeletal problems. were performed by using the terms of the test maneuver, the The knee is particularly susceptible to traumatic injury because joint tested, and the term physical examination. Any article of its vulnerable location midway between the hip and the with this information was reviewed until the article describing ankle, where it is exposed to the considerable forces transmit- the original description was found. Articles dating from that ted through the distal extremity from the ground. A thorough original article to the present were reviewed for information on examination of all knee structures should be a part of every the sensitivity and specificity of the test. knee evaluation. To ensure the most accurate diagnosis possi- Data Synthesis: Literature reviewing the sensitivity and ble, it is crucial that testing maneuvers be performed correctly specificity of the tests reviewed is summarized in text and table and that the examiner is aware of each maneuver’s sensitivity, form. The Lachman test seems to be very sensitive and specific specificity, and limitations. We reviewed the literature to find for the detection of anterior cruciate ligament tears. For pos- the original descriptions of commonly used physical examina- terior cruciate ligament tears, the posterior drawer test is also tion maneuvers of the knee and then searched the literature very sensitive and specific and is enhanced with other tests, again for studies that examined the sensitivity and specificity of such as the posterior sag sign. For meniscal tears, the McMur- these tests. ray test is very specific but has a very low sensitivity, whereas joint line tenderness has fairly good sensitivity but lacks good METHODS specificity. Although collateral ligament testing seems to be MEDLINE (1970–2000) searches were performed, as were sensitive and specific, there is a lack of well-designed studies reviews of various musculoskeletal examination textbooks. that scientifically validate the sensitivity and specificity of Key words used included knee, examination, anterior cruciate these tests. Common tests for patellofemoral pain and patellar ligament, posterior cruciate ligament, medial collateral liga- instability lack sensitivity when correlated with pathologic ment, lateral collateral ligament, patellofemoral pain, patellar operative findings. dislocation, McMurray test, Lachman test, anterior drawer Conclusions: Most physical examination tests could be ref- test, posterior drawer test, pivot shift test, apply grind test, erenced back to an original description, with variable informa- bounce home test, and grind test. The articles were obtained from local medical libraries and, when necessary, through interlibrary loan. The articles were then reviewed for additional references and searched back to the original description (when From the Kessler Institute for Rehabilitation, West Orange, NJ (Malanga, Andrus); possible) of the named tests. All articles that discussed the and Department of Physical Medicine and Rehabilitation, Univ of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, NJ (Malanga, Nadler, sensitivity and specificity of these tests were extracted. This McLean). information was reviewed for accuracy and then summarized. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any Tests for the Anterior Cruciate Ligament organization with which the authors are associated. Reprint requests to Gerard A. Malanga, MD, Spine, Sports and Occupational The anterior cruciate ligament (ACL) is among the main Rehabilitation, Kessler Institute for Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ 07052, e-mail: [email protected]. stabilizers of the knee, and injury to it often results in signif- 0003-9993/03/8404-7322$30.00/0 icant disability. Three of the most commonly applied tests to doi:10.1053/apmr.2003.50026 determine an ACL injury are the anterior drawer test, the Arch Phys Med Rehabil Vol 84, April 2003 PHYSICAL EXAMINATION TESTS OF THE KNEE, Malanga 593 Table 1: ACL Tests Test Description Reliability and Validity Tests Comments Anterior The subject is supine, hip Harilainen11 350 acute knees evaluated, with 79 arthroscopically confirmed drawer flexed to 45° and knee Sensitivity: 41% acute ACL injures. Prospective study. test flexed to 90°. Examiner sits Sensitivity (under anesthesia): 86% on the subject’s foot, with Katz and Fingeroth12 Testing performed only with patient under anesthesia. hands behind the proximal Sensitivity: 22.2% (acute injuries) tibia and thumbs on the Sensitivity: 53.8% (chronic injuries) Retrospective study. tibial plateau. Anterior force Specificity: Ͼ97% (acute and chronic) Limited sample size: 9 acute ACL injuries and 12 chronic. applied to the proximal Jonsson et al14 107 patients, all with documented acute or chronic ACL tibia. Hamstring tendons Sensitivity: 33% (acute injuries) ruptures. palpated with index fingers Sensitivity: 95% (chronic injuries) to ensure relaxation. Specificity not assessed because only positive ACL ruptures Increased tibial included. displacement compared Donaldson et al15 Retrospective study. with the opposite side is Sensitivity: 70% (acute injuries) Study not designed to evaluate specificity because authors indicative of an ACL tear. Sensitivity (under anesthesia): 91% reviewed only positive cases. Specificity: not reported Mitsou and Vallianatos16 144 knees, with 60 acute injuries all assessed within 3 days of Sensitivity: 40% (acute injuries) injury. In the group of 80 chronic injuries, the 4 false- Sensitivity: 95.24% (chronic injuries) negative drawer tests were associated with bucket-handle Specificity: not reported tears. Kim and Kim13 Testing performed only with patient under anesthesia. Sensitivity (under anesthesia): 79.6% Specificity. Not reported Retrospective study. Lachman Patient lies supine. Torg et al17 All ACL injuries were chronic. 93 knees with combined tears of test Knee held between full Sensitivity: 95% the ACL and median meniscus. All 5 false negatives were extension an 15° of flexion. Specificity: not reported associated with bucket-handle tears of the meniscus. Donaldson et al15 Retrospective study. Sensitivity: 99% Study not designed to evaluate specificity because authors Femur is stabilized with 1 Specificity: Not reported reviewed only positive cases. hand while firm pressure is Katz and Fingeroth12 Testing performed only with patient under anesthesia. applied to the posterior Sensitivity (under anesthesia): aspect of the proximal tibia 84.67% in an attempt to translate it Specificity (under anesthesia): 95% Retrospective study. anteriorly. Limited sample size: 9 acute ACL injuries and 12 chronic injuries. Test is positive (indicating Kim and Kim13 Testing performed only with patient under anesthesia. ACL rupture) when there is Sensitivity (under anesthesia): 98.6% anterior translation of the Specificity: not reported Retrospective review study. tibia with “soft” endpoint. Mitsou and Vallianatos16 All ACL injuries were chronic. 144 knees, with 60 acute injuries Sensitivity: 80% (acute injuries) all assessed within 3 days of injury. Sensitivity: 98.8% (chronic injuries) Jonsson et al14 107 patients, all with documented acute or chronic ACL Sensitivity: 87% (acute injuries) ruptures. Sensitivity: 94% (chronic injuries) Specificity not assessed because only positive ACL ruptures included.
Load more

Recommended publications
  • Effusion =S Fluid in Pleural Space (Outside of Lung) Fremitus - Pathophysiology • Fremitus: – Increased W/Consolidation (E.G
    General Part Head and Neck Cardiovascular Abdomen Lung Muscles Lung Exam • Includes Vital Signs & Cardiac Exam • 4 Elements (cardiac & abdominal too) – Observation – Palpation – Percussion – Auscultation Pulmonary Review of Systems • All organ systems have an ROS • Questions to uncover problems in area • Need to know right questions & what the responses might mean! Exposure Is Key – You Cant Examine What You Can’t See! Anatomy Of The Spine Cervical: 7 Vertebrae Thoracic: 12 Vertebrae Lumbar: 5 Vertebrae Sacrum: 5 Fused Vertebrae Note gentle curve ea segment Hammer & Nails icon indicates A Slide Describing Skills You Should Perform In Lab Spine Exam As Relates to the Thorax • W/patient standing, observe: – shape of spine. – Stand behind patient, bend @ waist – w/Scoliosis (curvature) one shoulder appears “higher” Pathologic Changes In Shape Of Spine – Can Affect Lung Function Scoliosis (curved to one side) Thoracic Kyphosis (bent forward) Observation • ? Ambulates w/out breathing difficulty? • Readily audible noises (e.g. wheezing)? • Appearance →? sitting up, leaning forward, inability to speak, pursed lips → significant compromise • ? Use of accessory muscles of neck (sternocleidomastoids, scalenes), inter-costals → significant compromise / Make Note of Chest Shape: Changes Can Give Insight into underlying Pathology Barrel Chested (hyperinflation secondary to emphysema) Examine Nails/Fingers: Sometimes Provides Clues to Pulmonary Disorders Cyanosis Nicotine Staining Clubbing Assorted other hand and arm abnormalities: Shape, color, deformity
    [Show full text]
  • Telemedicine Management of Musculoskeletal Issues Nicole T
    Telemedicine Management of Musculoskeletal Issues Nicole T. Yedlinsky, MD, University of Kansas Medical Center, Kansas City, Kansas Rebecca L. Peebles, DO, Ehrling Bergquist Family Medicine Residency Program, Offutt Air Force Base, Nebraska; Uniformed Services University of the Health Sciences, Bethesda, Maryland Telemedicine can provide patients with cost-effective, quality care. The coronavirus disease 2019 pandemic has highlighted the need for alternative methods of delivering health care. Family physi- cians can benefit from using a standardized approach to evaluate and diagnose musculoskeletal issues via telemedicine visits. Previsit planning establishes appropriate use of telemedicine and ensures that the patient and physician have functional telehealth equipment. Specific instructions to patients regard- ing ideal setting, camera angles, body positioning, and attire enhance virtual visits. Physicians can obtain a thorough history and perform a structured musculoskel- etal examination via telemedicine. The use of common household items allows physicians to replicate in-person clinical examination maneuvers. Home care instructions and online rehabilitation resources are available for ini- tial management. Patients should be scheduled for an in-person visit when the diagnosis or management plan is in question. Patients with a possible deformity or neuro- vascular compromise should be referred for urgent evaluation. Follow-up can be done virtually if the patient’s condition is improving as expected. If the condition is worsening or not improving, the patient should have an in-office assessment, with consideration for referral to formal physical therapy or spe- cialty services when appropriate. (Am Fam Physician. 2021;103:online. Copyright © 2021 American Academy of Family Physicians.) Illustration by Jennifer Fairman by Jennifer Illustration Published online January 12, 2021.
    [Show full text]
  • Netter's Musculoskeletal Flash Cards, 1E
    Netter’s Musculoskeletal Flash Cards Jennifer Hart, PA-C, ATC Mark D. Miller, MD University of Virginia This page intentionally left blank Preface In a world dominated by electronics and gadgetry, learning from fl ash cards remains a reassuringly “tried and true” method of building knowledge. They taught us subtraction and multiplication tables when we were young, and here we use them to navigate the basics of musculoskeletal medicine. Netter illustrations are supplemented with clinical, radiographic, and arthroscopic images to review the most common musculoskeletal diseases. These cards provide the user with a steadfast tool for the very best kind of learning—that which is self directed. “Learning is not attained by chance, it must be sought for with ardor and attended to with diligence.” —Abigail Adams (1744–1818) “It’s that moment of dawning comprehension I live for!” —Calvin (Calvin and Hobbes) Jennifer Hart, PA-C, ATC Mark D. Miller, MD Netter’s Musculoskeletal Flash Cards 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 NETTER’S MUSCULOSKELETAL FLASH CARDS ISBN: 978-1-4160-4630-1 Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this book may be produced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission in writing from the publishers. Permissions for Netter Art figures may be sought directly from Elsevier’s Health Science Licensing Department in Philadelphia PA, USA: phone 1-800-523-1649, ext. 3276 or (215) 239-3276; or e-mail [email protected].
    [Show full text]
  • Cervical Spine Injuries
    Essential Sports Medicine Essential Sports Medicine Joseph E. Herrera Editor Department of Rehabilitation Medicine, Interventional Spine and Sports, Mount Sinai Medical Center New York, NY Grant Cooper Editor New York Presbyterian Hospital New York, NY Editors Joseph E. Herrera Grant Cooper Department of Rehabilitation Medicine New York Presbyterian Hospital Interventional Spine & Sports New York, NY Mount Sinai Medical Center New York, NY Series Editors Grant Cooper Joseph E. Herrera New York Presbyterian Hospital Department of Rehabilitation Medicine New York, NY Interventional Spine and Sports Mount Sinai Medical Center New York, NY ISBN: 978-1-58829-985-7 e-ISBN: 978-1-59745-414-8 DOI: 10.1007/978-1-59745-414-8 Library of Congress Control Number © 2008 Humana Press, a part of Springer Science + Business Media, LLC All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Humana Press, 999 Riverview Drive, Suite 208, Totowa, NJ 07512 USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made.
    [Show full text]
  • Meniscus Injury
    Introduction Role of menisci • Medial meniscus lesions are more common than 01 lateral meniscus because it is attached to the improving articular capsule that make it less mobile thus it cannot congruency and increasing easily to accommodate the abnormal stresses. the stability of the knee • In increasing age – gradual degeneration and change in the material properties of the menisci Meniscus controlling the complex thus splits and tears are more likely that usually associated with osteoarthritic articular damage or rolling and gliding actions of chondrocalcinosis. Injury the joint • In younger people - meniscal tears are usually the result of trauma, with a specific injury identified in distributing load during the history. movement Tear of Meniscus Pathology Pathology • Usually, meniscus more likely to tear along its Vertical tear Horizontal tear length than across its width because the Bucket-handle tear usually ‘degenerative’ or due to repetitive minor trauma meniscus consists mainly of circumferential the separated fragment remains attached front complex with the tear pattern lying in many collagen fibres held by a few radial strands. and back planes The torn portion can sometimes displace towards may be displaced or likely to displace • The meniscus is usually torn by a twisting the centre of the joint and becomes jammed If the loose piece of meniscus can be displaced, it between femur and tibia acts as a mechanical irritant, giving rise to force with the knee bent and taking weight. This causes a block to movement with the patient recurrent synovial effusion and mechanical describing a ‘locked knee’ symptoms • In middle life, tears can occur with relatively posterior or anterior horn tears Some are associated with meniscal cysts little force when fibrotic change has the very back or front of the meniscus is It is also suggested that synovial cells infiltrate into the vascular area between meniscus and restricted mobility of the meniscus.
    [Show full text]
  • Knee Examination (ACL Tear) (Please Tick)
    Year 4 Formative OSCE (September) 2018 Station 3 Year 4 Formative OSCE (September) 2018 Reading for Station 3 Candidate Instructions Clinical Scenario You are an ED intern at the Gold Coast University Hospital. Alex Jones, 20-years-old, was brought into the hospital by ambulance. Alex presents with knee pain following an injury playing soccer a few hours ago. Alex has already been sent for an X-ray. The registrar has asked you to examine Alex. Task In the first six (6) minutes: • Perform an appropriate physical examination of Alex and explain what you are doing to the registrar as you go. In the last two (2) minutes, you will be given Alex’s X-ray and will be prompted to: • Interpret the radiograph • Provide a provisional diagnosis to the registrar • Provide a management plan to the registrar You do not need to take a history. The examiner will assume the role of the registrar. Year 4 Formative OSCE (September) 2018 Station 3 Simulated Patient Information The candidate has the following scenario and task Clinical Scenario You are an ED intern at the Gold Coast University Hospital. Alex Jones, 20-years-old, was brought into the hospital by ambulance. Alex presents with knee pain following an injury playing soccer a few hours ago. Alex has already been sent for an X-ray. The registrar has asked you to examine Alex. Task In the first six (6) minutes: • Perform an appropriate physical examination of Alex and explain what you are doing to the registrar as you go. In the last two (2) minutes, you will be given Alex’s X-ray and will be prompted to: • Interpret the radiograph • Provide a provisional diagnosis to the registrar • Provide a management plan to the registrar You do not need to take a history.
    [Show full text]
  • Comparison of the Thesslay Test and Mcmurray Test: a Systematic
    py & Ph ra ys e i th c Alexanders et al.,Physiother Rehabil 2016, 1:1 a io l s R y e Journal of DOI: 10.4172/2573-0312.1000104 h h a P b f i o l i l t a ISSN:a 2573-0312 t n i r o u n o J Physiotherapy & Physical Rehabilitation Research Article Open Access Comparison of the Thesslay Test and McMurray Test: A Systematic Review of Comparative Diagnostic Studies Jenny Alexanders1*, Anna Anderson2, Sarah Henderson1 and Ulf Clausen3 1Sport, Health and Sciences Department, The University of Hull, Washburn Building, Cottingham Road, Hull, United Kingdom 2Leeds Teaching Hospitals, Beckett Street, Leeds, LS9 7TF, United Kingdom 3Dr Hill and Partners, Beverly Health Practice, Manor Road, Hull, HU17 7BZ, United Kingdom Abstract Background: The Thessaly test is a relatively recently developed meniscal test; therefore research compared to other meniscal tests is somewhat limited. In addition, a systematic review comparing the Thessaly’s test with a long standing test such as the McMurray test has not been previously conducted. Objective: To systematically identify and appraise all empirical studies comparing the diagnostic accuracy of the Thessaly test and McMurray test. Procedure: Eligible studies were identified through a rigorous search of ScienceDirect, CINAHL Plus, Pubmed, PEDro, EMBASE and Cochrane Library from January 2004 until August 2014. Full English reports of studies investigating the accuracy of the Thessaly test and McMurray test. Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) scores were completed on each selected article. Results: The Thessaly test reported to have higher diagnostic accuracy values (61-96%) compared to the McMurray test (56-84%).
    [Show full text]
  • Physical Esxam
    Pearls in the Musculoskeletal Exam Frank Caruso MPS, PA-C, EMT-P Skin, Bones, Hearts & Private Parts 2019 Examination Key Points • Area that needs to be examined, gown your patients - well exposed • Understand normal functional anatomy • Observe normal activity • Palpation • Range of Motion • Strength/neuro-vascular assessment • Special Tests General Exam Musculoskeletal Overview Physical Exam Preview Watch Your Patients Walk!! Inspection • Posture – Erectness – Symmetry – Alignment • Skin and subcutaneous tissues – Swelling – Redness – Masses Inspection • Extremities – Size – Deformities – Enlargement – Alignment – Contour – Symmetry Inspection • Muscles – Bilateral symmetry – Hypertrophy – Atrophy – Fasciculations – Spasms Palpation • Palpate bones, joints, and surrounding muscles for the following: – Heat – Tenderness – Swelling – Fluctuation – Crepitus – Resistance to pressure – Muscle tone Muscles • Size and strength affected by the following: – Genetics – Exercise – Nutrition • Muscles move joints through range of motion (ROM). Muscle Strength • Compare bilateral muscles – Strength – Symmetry – Equality – Resistance End Feel Think About It!! • The sensation the examiner feels in the joint as it reaches the end of the range of motion of each passive movement • Bone to bone: This is hard, unyielding – normal would be elbow extension. • Soft–tissue approximation: yielding compression that stops further movement – elbow and knee flexion. End Feel • Tissue stretch: hard – springy type of movement with a slight give – toward the end of range of motion – most common type of normal end feel : knee extension and metacarpophalangeal joint extension. Abnormal End Feel • Muscle spasm: invoked by movement with a sudden dramatic arrest of movement often accompanied by pain - sudden hard – “vibrant twang” • Capsular: Similar to tissue stretch but it does not occur where one would expect – range of motion usually reduced.
    [Show full text]
  • Evaluation and Management of Sports Injuries in Children
    2019 Frontiers in Pediatrics Sports Medicine Mini-Symposium Presented by MUSC Health Sports Medicine Sports Medicine Panel of Experts Michael J. Barr, PT, DPT, MSR Sports Medicine Manager MUSC Health Sports Medicine Alec DeCastro, MD Assistant Professor CAQ Sports Medicine Director, MUSC/Trident Family Medicine Residency MUSC Health Sports Medicine MUSC Department of Family Medicine Harris S. Slone, MD Associate Professor Orthopaedic Surgery and Sports Medicine MUSC Health Sports Medicine MUSC Department of Orthopaedics Sports Medicine Breakout Group Leaders Aaron Brown, ATC Athletic Trainer MUSC Health Sports Medicine Amelia Brown, MS, ATC Athletic Trainer MUSC Health Sports Medicine Brittney Lang, MS, ATC Athletic Trainer MUSC Health Sports Medicine Bobby Weisenberger, MS, ATC, PES Athletic Trainer MUSC Health Sports Medicine Sports Medicine Schedule Approximate Timeline: 2:00: Introduction – Michael Barr, PT, DPT, MSR – Sports Medicine Manager 2:05: Ankle Case Report – Harris Slone, MD 2:20: Knee Case Report – Harris Slone, MD 2:35: Shoulder Instability Case Report – Michael Barr, PT, DPT, MSR 2:50: Back Case Report – Alec DeCastro, MD 3:05: High BP Case Report – Alec DeCastro, MD 3:20: Hands On Practice of Exam Techniques – All + Athletic Trainers 3:50: Question/Answer Open Forum – All 4:00: End Sports Medicine Disclosers No relevant financial disclosers Sports Medicine Learning Objectives Learning Objectives: 1. Describe mechanisms of injury and clinical presentation for common pediatric sports related injuries of the ankle, knee, back and shoulder. 2. Demonstrate examination techniques to support the diagnosis of common pediatric sports related injuries of the ankle, knee, back and shoulder 3. Determine what imaging studies should be ordered and when to refer to a sports med/orthopaedic surgeon or to physical therapy 4.
    [Show full text]
  • Examination of the Knee
    Examination of the Knee The Examination For every joint of the lower extremity always begin with the patient in standing IN STANDING INSPECTION 1. Cutaneous Structures: Look for Erythema, scarring, bruising, and swelling in the following areas: a. Peripatellar grooves b. Suprapatellar bursa c. Prepatellar bursa d. Infrapatellar tendon e. Anserine bursa f. Popliteal fossa 2. Muscle & Soft Tissue: a. Quadriceps atrophy b. Hamstring atrophy c. Calf atrophy 3. Bones & Alignment: a. Patella position (Alta, Baha, Winking, Frog eyed), b. Varus or Valgus alignment c. Flexion contracture or Genu recurvatum RANGE OF MOTION - ACTIVE Standing is the best opportunity to assess active range of motion of the knee. 1. Ask the patient to squat into a deep knee bend. Both knees should bend symmetrically. 2. Ask the patient to then stand and extend the knee fully – lock the knee. The knee should straighten to 0 degrees of extension. Some people have increased extension referred to as genu recurvatum. GAIT 1. Look for a short stance phase on the affected limb and an awkward gait if a concomitant leg length discrepancy 2. Look for turning on block 3. Screening 1. Walk on the toes 2. Walk on the heels 3. Squat down – Active Range of Motion testing SPECIAL TESTS 1. Leg Length Discrepancy a. Look at patients back for evidence of a functional scoliosis b. Place your hands on the patients Iliac crests looking for inequality which may mean a leg length discrepancy IN SITTING NEUROLOGIC EXAMINATION 1. Test the reflexes a. L4 – Quadriceps reflex VASCULAR EXAMINATION 1. Feel for the posterior tibial artery SUPINE POSITION INSPECTION 1.
    [Show full text]
  • SIMMONDS TEST:  Patient Is Prone  Doctor Flexes the Patients Knee to 90 Degrees  Doctor Squeezes the Patient’S Calf
    Clinical Orthopedic Testing Review SIMMONDS TEST: Patient is prone Doctor flexes the patients knee to 90 degrees Doctor squeezes the patient’s calf. Classical response: Failure of ankle plantarflexion Classical Importance= torn Achilles tendon Test is done bilaterally ACHILLES TAP: Patient is prone Doctor flexes the patient’s knee to 90 degree Doctor dorsiflexes the ankle and then strikes the Achilles tendon with a percussion hammer Classical response: Plantar response Classical Importance= Intact Achilles tendon Test is done bilaterally FOOT DRAWER TEST: Patient is supine with their ankles off the edge of the examination table Doctor grasps the heel of the ankle being tested with one hand and the tibia just above the ankle with the other. Doctor applies and anterior to posterior and then a posterior to anterior sheer force. Classical response: Anterior or posterior translation of the ankle Classical Importance= Anterior talofibular or posterior talofibular ligament laxity. Test is done bilaterally LATERAL STABILITY TEST: Patient is supine Doctor grasps the tibia with one hand and the foot with the other. Doctor rotates the foot into inversion Classical response: Excessive inversion Classical Importance= Anterior talofibular ligament sprain Test is done bilaterally MEDIAL STABILITY TEST: Patient is supine Doctor grasps the tibia with one hand and the foot with the other Doctor rotates the foot into eversion Classical response: Excessive eversion Classical Importance= Deltoid ligament sprain Test is done bilaterally 1 Clinical Orthopedic Testing Review KLEIGER’S TEST: Patient is seated with the legs and feet dangling off the edge of the examination table. Doctor grasps the patient’s foot while stabilizing the tibia with the other hand Doctor pulls the ankle laterally.
    [Show full text]
  • Knee Pain in Children: Part I: Evaluation
    Knee Pain in Children: Part I: Evaluation Michael Wolf, MD* *Pediatrics and Orthopedic Surgery, St Christopher’s Hospital for Children, Philadelphia, PA. Practice Gap Clinicians who evaluate knee pain must understand how the history and physical examination findings direct the diagnostic process and subsequent management. Objectives After reading this article, the reader should be able to: 1. Obtain an appropriate history and perform a thorough physical examination of a patient presenting with knee pain. 2. Employ an algorithm based on history and physical findings to direct further evaluation and management. HISTORY Obtaining a thorough patient history is crucial in identifying the cause of knee pain in a child (Table). For example, a history of significant swelling without trauma suggests bacterial infection, inflammatory conditions, or less likely, intra- articular derangement. A history of swelling after trauma is concerning for potential intra-articular derangement. A report of warmth or erythema merits consideration of bacterial in- fection or inflammatory conditions, and mechanical symptoms (eg, lock- ing, catching, instability) should prompt consideration of intra-articular derangement. Nighttime pain and systemic symptoms (eg, fever, sweats, night sweats, anorexia, malaise, fatigue, weight loss) are associated with bacterial infections, inflammatory conditions, benign and malignant musculoskeletal tumors, and other systemic malignancies. A history of rash or known systemic inflammatory conditions, such as systemic lupus erythematosus or inflammatory bowel disease, should raise suspicion for inflammatory arthritis. Ascertaining the location of the pain also can aid in determining the cause of knee pain. Anterior pain suggests patellofemoral syndrome or instability, quad- riceps or patellar tendinopathy, prepatellar bursitis, or apophysitis (patellar or tibial tubercle).
    [Show full text]